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International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx

IJG-08412; No of Pages 4

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics

j ourna l homepage: www.e lsev ie r .com/ locate / i jgo

CLINICAL ARTICLE

Effect of perineal massage on the rate of episiotomy and perineal tearing

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Gulbahtiyar Demirel a,⁎, Zehra Golbasi b

a Department of Midwifery, Faculty of Health Sciences, Cumhuriyet University, Sivas, Turkeyb Department of Nursing, Faculty of Health Sciences, Cumhuriyet University, Sivas, Turkey

⁎ Corresponding author at: Department of MidwiferCumhuriyet University, Sivas 58140, Turkey. Tel.: +3462191261.

E-mail address: gulbahtiyar_doganer@hotmail.com (G

http://dx.doi.org/10.1016/j.ijgo.2015.04.0480020-7292/© 2015 Published by Elsevier Ireland Ltd. on b

Please cite this article as: Demirel G, Golbas(2015), http://dx.doi.org/10.1016/j.ijgo.2015

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Received 4 July 2014Received in revised form 24 April 2015Accepted 13 July 2015

Keywords:Duration of the second stage of laborEpisiotomyPerineal lacerationPerineal massage

Objective: To examine the effects of perineal massage during active labor on the frequency of episiotomy and per-ineal tearing. Methods: A randomized controlled study was conducted at a center in Sivas, Turkey, betweenJanuary 1, 2010, and May 31, 2011. Healthy pregnant women presenting for their first or second delivery at37–42 weeks of pregnancy were enrolled during the first stage of labor. Participants were randomly assigned(1:1) to the massage group (10-minute perineal massage with glycerol four times during the first stage andonce during the second stage of labor) or control group (routine care). The frequency of episiotomy and perinealtearing were compared between the groups. Participants and investigators were not masked to group assign-ment. Results: Both groups contained 142 participants. Episiotomy was performed among 44 (31.0%) womenin the massage group and 99 (69.7%) in the control group (P = 0.001). Lacerations were recorded among 13

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D(4.2%)women in themassage group and 6 (4.2%) in the control group (P=0.096).Conclusion:Application of per-ineal massage during active labor decreased the frequency of episiotomy procedures.

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EClinicalTrials.gov: NCT02201615© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

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RREC1. Introduction

Perineal trauma—spontaneous or episiotomy-induced damage tothe genital organs during delivery [1]—affects the quality of activelabor, especially among primiparous women [2,3]. It is frequently ob-served during delivery and can have detrimental effects on a mother’shealth and quality of life [3]. Women who experience perineal traumacan subsequently be affected by conditions such as dyspareunia, urinaryand anal incontinence, perineal pain, and delayed mother–neonateinteraction [4–6].

Perineal trauma can be caused by episiotomy [2,3]—one of the mostfrequently used obstetric interventions [7,8]. Although some studiesargue that performance of episiotomy should be limited owing to thenegative effects of perineal trauma on maternal and neonatal health[8,9], this obstetric procedure continues to be widely applied in manycountries. For example, the prevalence of episiotomy is 8% in theNetherlands, 14% in the UK, 50% in the USA, and as high as 99% inmany eastern European countries [10]. One study found that episiotomyis performed in more than 65% of all deliveries and more than 90% ofthose among primiparous women in Turkish hospitals [11]. Anotherfound that the rate of episiotomy among all deliveries was 74.2% [12].

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Overall, episiotomy is still routinely used in Turkey among primiparouswomen and women with two or more previous deliveries [13,14].

The accumulation of evidence that episiotomy does not ensureperineum integrity and has overwhelming negative effects has ledto an increase in the number of studies on other protective variables(e.g. prenatal perineal massage and hot treatment) [2,3]. Perineal-protective birth techniques are recommended to prevent perineallacerations and their associated morbidity [3,15]. Perineal massage canprevent perineal lacerations, protect perineal integrity, and enablewomen to rapidly regain function after delivery [2,3,5]. It can stimulateboth rehabilitation and the re-elasticization of tissues and muscles, andis thought to have a positive effect on vaginal delivery owing to its im-pact on tissues and muscles in the perineal area [2,3].

However, previous studies have provided varied results regardingthe effectiveness of perineal massage for the prevention of perinealtrauma. Some studies indicated that prenatal perineal massage [2,3,13] and perineal massage during the second stage of active labor [16,17] reduce the rate of perineal trauma. By contrast, others have reportedthat perineal massage provides neither an advantage nor a disadvan-tage in terms of the rate of perineal trauma [1,6]. Thus, further studiesare needed on whether perineal massage secures perineal integrity. Inaddition, there are few studies on the application of perineal massageduring both the first and second stages of labor.

As a result, the aim of the present studywas to examine the effects ofperineal massage applied during labor on the frequency of episiotomyprocedures and perineal tearing. A secondary aim was to assess the ef-fect of massage on the duration of the second stage of labor.

ynecology and Obstetrics.

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2. Materials and methods

The present randomized controlled study was conducted betweenJanuary 1, 2010, and May 31, 2011 among pregnant women presentingfor delivery at Sivas State Hospital, Sivas, Turkey—a hospital with ap-proximately 3200 normal vaginal births per year. Women were eligiblefor inclusion when they had had no pregnancy-related complicationsduring pregnancy, they had no systemic condition, it was their first orsecond birth, the fetus was in cephalic presentation, they had no defin-itive indication for cesarean delivery, theywere at 37–42weeks of preg-nancy with verification of fetal dimensions, and they were in the latentphase of the first stage of labor with dilatation of less than 4 cm andeffacement of less than 50%.

Ethical approval (decision no. 2009-12/07) was obtained fromthe Ethics Board for Clinical Research at Cumhuriyet University,Sivas, Turkey, and written approval was obtained from the study insti-tution. All women participated voluntarily and provided writteninformed consent.

On arrival at the hospital, pregnant women were given a pre-evaluation form and assessed for compliancewith the inclusion criteria.Women who were eligible and agreed to participate were then dividedon the basis of parity (primiparous andmultiparous). After the start col-umn in a table of random numbers was designated by one researcher(G.D.), the primiparous pregnant women were randomly assigned(1:1) to the two groups by starting with the first number for the controlgroup, the second number for the massage group, and so on. The mul-tiparous pregnant women were randomly assigned to the two groupsin the same way. Participants and investigators were not masked togroup assignment.

Perineal massage was administered to all women in the massagegroup in the first stage of labor. The massage was performed in linewith a previous report [13]. Before massage was started, it was en-sured that the bladder and bowel of the patient was empty. Each par-ticipant lay on her back in the lithotomic position, because in thisposition, the abdominal muscles and hips are relaxed. The restingphase, when the severity of contractions was reduced, was chosenfor the massage. In this phase, one researcher (G.D.) washed theirhands and put on gloves. Next, they poured a few drops of the lubri-cant (glycerol) onto their fingers and placed two thumbs 2–3 cm intothe vagina and applied pressure to the vaginal lateral walls withtheir thumbs. Pressure was maintained at an intensity at which thewoman did not feel any pain. The pressurizing action was continuedfor 2 minutes. Alongside the massage, the woman was asked to con-tract and relax the muscles in the perineal area and to become awareof these muscles. The massage was paused at the onset of contrac-tions and resumed when the contractions subdued. The massagecontinued for 10 minutes in this manner. The participant was thenallowed to rest for a minimum of 30 minutes before the 10-minutemassage was repeated. The massage was performed four times dur-ing the first stage of labor. When approaching the second stage oflabor, each patient was taken to an obstetric table and received an-other 10 minutes of perineal massage. Women in the control groupreceived routine care.

After delivery, the massage and control groups were evaluated interms of the rate of episiotomy and perineal tearing, and the durationof the second stage of labor (Supplementary Material S1). In bothgroups, women would be delivered by cesarean if necessary.

The necessary sample size was calculated by power analysis.Previous studies indicate that the rate of intact perinea can be increasedby 10% by applying prenatal perineal massage [3,18]. In 2009, the fre-quency of episiotomy procedures at Sivas State Hospital was 63%among all pregnant women and 99% among primiparous women. Thesample size needed to obtain a significant difference with an α valueof 0.05, a confidence level of 1–α of 0.95, a β value of 0.20, and apower of 1–β of 0.80 was identified as 284 individuals. Equal numbersof primiparous and multiparous women were approached.

Please cite this article as: Demirel G, Golbasi Z, Effect of perineal massag(2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.048

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The study data were evaluated using SPSS version 14.0 (SPSS Inc,Chicago, IL, USA). Women who received their assigned treatmentwere included in analyses. The rates of episiotomy and spontaneous lac-eration were compared between the massage and control groups by χ2

test, and the average duration of the second stage was compared by anindependent two-sample t test. P b 0.05 was considered significant.

3. Results

During the study period, 284 women met the inclusion criteria andagreed to participate (Fig. 1). Both groups contained 142 patients. Allparticipants completed the study and were included in analyses. Thecontrol and massage groups both contained 71 multiparous pregnantwomen. No significant differences between groups were recorded forage, length of pregnancy, or neonatal head circumference (Table 1).No women delivered by cesarean.

Episiotomy was significantly more common in the control groupthan in the massage group (P = 0.001) (Table 2). Frequency of lacera-tion did not differ significantly between groups (P = 0.096) (Table 2).

The mean duration of the second stage of labor was significantlyshorter in the massage group than in the control group among thewhole population, among primipara, and among multipara (P b 0.01for all) (Table 3).

4. Discussion

In the present study, the effects of glycerol-mediated perineal mas-sage applied during the first and second stages of labor were comparedagainst a control group of women who received no massage. The mas-sage and control groups did not differ in maternal age, gestational age,or neonatal head circumference, increasing the reliability of the presentfindings. Compared with the control group, significantly fewer womenwho had received perineal massage underwent episiotomy, indicatinga positive effect of perineal massaging applied during the first and sec-ond stages of labor.

Previous studies have reported varied results on the effects ofperinealmassage in thefirst stage of labor on the rate of episiotomypro-cedures. For example, Mei-dan et al. [1] did not find a significant differ-ence in the rate of episiotomy between women who received perinealmassage (20% of 23 women) and those who did not receive such mas-sage (19% of 20 women). By contrast, Sayiner and Demirci [13] foundthat the rate of episiotomy procedures among women who had under-gone prenatal perineal massage (10% of 5) was significantly lower thanthat in the control group (92% of 46). Other studies have also suggestedthat perineal massage initiated in the prenatal period decreases thenumber of episiotomy procedures [3,18].

Whether perineal massage during the second stage of labor reducesthe rates of episiotomy has also been examined [6,16,17]. For example,Karaçam et al. [6] found that the frequency of episiotomy proceduresamong women who had received perineal massage during the secondstage of labor (52.0% of 103 women) was lower than that in the controlgroup (60.6% of 120). In another study of the effect of perineal massageduring the second stage of labor, however, Geranmayeh et al. [17] didnot observe a difference in episiotomy rate between the massage (45%of 15) and control (88% of 38) groups.

The present study differs from previous ones in that perineal mas-sage was applied during both the first and second stages of labor. Thevaried results regarding the effect of perinealmassage on the rate of epi-siotomy procedures among different studies are thought to stem fromvariations in the timing of perinealmassage (i.e. prenatal period, secondstage only, or first and second stages).

Because the present sample included only healthy pregnant womenhaving their first or second birth, the results cannot be generalized tothe whole population. However, the findings still have implications forperineal complications associated with labor.

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t1:1 Table 1t1:2 Individual and obstetric characteristics.a

t1:3 Characteristic Overall (n = 284) Massage group (n = 142) Control group (n = 142) t statistic P value

t1:4 Age, y 23.86 ± 3.94 24.30 ± 4.09 23.42 ± 3.74 1.891 0.060t1:5 Length of pregnancy, wk 38.58 ± 0.93 38.58 ± 0.99 38.59 ± 0.87 −0.190 0.850t1:6 Neonatal head circumference, cm 35.78 ± 0.87 35.80 ± 0.94 35.76 ± 0.79 0.475 0.635t1:7 Parity – –t1:8 Primiparous 142 (50.0) 71 (50.0) 71 (50.0)t1:9 Multiparous 142 (50.0) 71 (50.0) 71 (50.0)

t1:10 a Values are given as mean ± SD or number (percentage), unless indicated otherwise.

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t2:10

Assessed for eligibility (n=635)

Excluded (n=351) Did not meet inclusion criteria (n=147) Declined to participate (n=204)

Allocated to massage group (n=142) Allocated to control group (n=142)

Received routine care (n=142)

Primiparous (n=71)

Multiparous (n=71)

Randomly assigned (n=284)

Underwent perineal massage (n=142)

Primiparous (n=71)

Multiparous (n=71)

Fig. 1. Flow of patients through the study.

3G. Demirel, Z. Golbasi / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx

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RRECPerinealmassaging is recommended because it improves the elastic-

ity of the perineal muscles, ensures perineal flexibility during delivery,and thereby reduces both the need for episiotomy and spontaneous lac-erations [13,19]. In a study in Canada, Labreque et al. [18] determinedthat perinatal perineal massaging increased the rate of intact perineumfrom 15% to 24%. Other studies also reported a higher rate of intact per-ineum and fewer lacerations in perineal massage groups [2,16,17], butsome studies failed to identify such effects [1,20]. Sayiner and Demirci[13] established a rate of spontaneous laceration of 12% (6 women) inthe prenatal perineal massage group and 2% (1 woman) in the controlgroup. In the present study, 9.2% of women in themassage group devel-oped lacerations, as comparedwith 4.2% ofwomen in the control group;thus, the rate of spontaneous laceration in themassage groupwas lowerthan that reported by Sayiner and Demirci [13]. This finding may sug-gest that massage applied during the first and second stages of labormore effectively avoids spontaneous laceration than does massage ap-plied only during the prenatal period.

It is difficult to assess the present data on the duration of the secondstage objectively owing to the limited number of studies on the ideal

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Table 2Frequency of laceration and episiotomy procedures.a

Characteristic Overall(n = 284)

Massage group(n = 142)

Control group(n = 142)

χ2

statisticP value

Laceration 2.764 0.096Yes 19 (6.7) 13 (9.2) 6 (4.2)No 265 (93.3) 129 (90.8) 136 (95.8)

Episiotomy 42.608 0.001Yes 143 (50.4) 44 (31.0) 99 (69.7)No 141 (49.6) 98 (69.0) 43 (30.3)

a Values are given as number (percentage) unless indicated otherwise.

Please cite this article as: Demirel G, Golbasi Z, Effect of perineal massage(2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.048

duration of this stage of labor [21]. One study has specified the durationof the second stage as lasting from 30 minutes to 2 hours for primipa-rous women and from 5 minutes to 30 minutes for multiparouswomen [7]. The second stage of labor has been reported to be longerfor women undergoing episiotomy [22,23], and shorter for womenundergoing perineal massage [17]. For example, Geranmayeh et al.[17] observed that the second stage of labor lasted 37 ± 20 minutes intheir perineal massage group and 46 ± 19 minutes in their controlgroup. In the present study, the average duration of the second stagewas significantly shorter in the massage group than in the controlgroup. It was also significantly shorter in themassage group among pri-miparous women and among multiparous women. These data indicatethat perinealmassage applied during thefirst and second stages of laborshortened the duration of the second stage. These results should be con-firmed in a larger and wider study sample.

In summary, the present study results indicate that application ofperineal massage during the first and second stages of active laborcould decrease the rate of episiotomy procedures and shorten the dura-tion of the second stage of labor.

t3:1Table 3t3:2Duration of the second stage of labor.a

t3:3Subgroup Massage group Control group t statistic P value

t3:4Primiparousb 29.63 ± 3.58 33.96 ± 3.78 −7.032 0.001t3:5Multiparousb 21.04 ± 3.42 22.38 ± 2.19 −2.770 0.006t3:6Overallc 25.33 ± 5.50 28.18 ± 6.58 −3.935 0.001

t3:7a Values are given as mean ± SD and are in minutes.t3:8b n = 71 for both groups.t3:9c n = 142 for both groups.

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4 G. Demirel, Z. Golbasi / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx

Supplementary data to this article can be found online at http://dx.doi.org/10.1016/j.ijgo.2015.04.048.

Acknowledgments

The present study was supported by the Scientific ResearchProject Fund of Cumhuriyet University, Sivas, Turkey (project numberSBF-005).

Conflict of interest

The authors have no conflicts of interest.

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